Setting Of Blunt Trauma Research Articles

A Descriptive Analysis of Traction Splint Utilization and IV Analgesia by Emergency Medical Services.

This is a retrospective study of patients who sustained a midshaft femur fracture in the absence of multiple other severe injuries or severe physiologic derangement, as defined by an injury severity score (ISS) <20 and a triage revised trauma score (T-RTS)≥10, who presented to an urban, Level 1 trauma center between September 2008 and September 2013. The EMS patient care reports were assessed for physical exam findings and treatment modality. Data were analyzed descriptively and statistical differences were assessed using odds ratios and Z-score with significance set at P≤.05. There were 170 patients studied in the cohort. The most common physical exam finding was a deformity +/- shortening and rotation in 136 patients (80.0%), followed by gunshot wound (GSW) in 22 patients (13.0%), pain or tenderness in four patients (2.4%), and no findings consistent with femur fracture in three patients (1.7%). The population was dichotomized between trauma type: blunt versus penetrating. Of 134 blunt trauma patients, 50 (37.0%) were immobilized in traction, and of the 36 penetrating trauma victims, one (2.7%) was immobilized in traction. Statistically significant differences were found in the application of a TS in blunt trauma when compared to penetrating trauma (OR=20.83; 95% CI, 2.77-156.8; P <.001). Intravenous analgesia was administered to treat pain in only 35 (22.0%) of the patients who had obtainable IV access. Of these patients, victims of blunt trauma were more likely to receive IV analgesia (OR=6.23; 95% CI, 1.42-27.41; P=.0067). Although signs of femur fracture are recognized in the majority of cases of midshaft femur fracture, only 30% of patients were immobilized using a TS. Statistically significant differences were found in the utilization of a TS and IV analgesia administration in the setting of blunt trauma when compared to penetrating trauma. Nackenson J , Baez AA , Meizoso JP . A descriptive analysis of traction splint utilization and IV analgesia by Emergency Medical Services.Prehosp Disaster Med. 2017;32(6):631-635.

A case of chylothorax following thoracic vertebral fracture

Occurrence of chylothorax following blunt trauma chest is usually rare. The possible presence of an underlying hemothorax or an empyema makes the diagnosis difficult in blunt trauma setting. We report a case of chylothorax following blunt trauma chest, diagnosed three days after, admission secondary to thoracic vertebral fracture. This case is being presented to emphasize the importance of occult thoracic spine injuries in a case of blunt trauma chest, and to have a high index of suspicion for the proper diagnosis of chylothorax in such cases.

Emergency Computed Tomography Angiogram of the Chest, Abdomen, and Pelvis

In the setting of blunt trauma, the rapid assessment of internal injuries is essential to prevent potentially fatal outcomes. Computed tomography is a useful diagnostic tool for both screening and diagnosis. In addition to trauma, acute chest syndromes often warrant emergent computed tomographic angiography, looking for etiologies such as aortic aneurysms or complications of aortic aneurysms, or both, pulmonary emboli, as well as other acute vascular process like aortic dissection and Takayasu aortitis. With continued improvements in diagnostic imaging, computed tomographic angiography of the chest, abdominal and pelvis proves to be an effective modality to image the aorta and other major vascular structures.

Parenchymal Injuries

Injuries to lung parenchyma are common, but in the majority of cases supportive management is sufficient. In the setting of blunt trauma, primary concerns are acute or delayed respiratory compromise including pneumonia or adult respiratory distress syndrome (ARDS). In the setting of penetrating injury, the most common indication for surgery is active hemorrhage and, less commonly, significant air leak. If surgery is required, the primary goal is to preserve as much parenchyma as possible, which is associated with improved survival. Keywords: Lung, parenchyma, contusion, thoracotomy, trauma.

Isolated epididymal injury after blunt scrotal trauma from high velocity paintball round.

Isolated epididymal injury without associated underlying scrotal or testicular injury in the setting of blunt trauma is exceedingly rare. We present a case of an isolated epididymal injury incurred after scrotal trauma from a high velocity paintball round. Ultrasound demonstrated an enlarged, hypoechoic left epididymis with no evidence of underlying testicular injury. This case highlights the importance of obtaining imaging to evaluate for signs of testicular rupture, potentially obviating the need for surgery. It also reinforces the need for appropriate protective gear when participating in activities with potential for high velocity scrotal trauma.

Reformatted images of the thoracic and lumbar spine following CT of chest, abdomen, and pelvis in the setting of blunt trauma: are they necessary?

Injuries involving the thoracic and lumbar (TL) spine in the setting of blunt trauma are not uncommon. At our institution, CT of the chest, abdomen, and pelvis (CT CAP) with dedicated reformatted images of the thoracolumbar spine (CT TL) is part of the standard work-up of patients following significant blunt trauma. The purpose of this study was to compare the detection rate of TL spine fractures on routine trauma CT CAP with reformatted CT TL spine images and determine whether these reformatted images detect additional fractures and if these altered patient management. The imaging records of 1000 consecutive patients who received blunt trauma protocol CT CAP with CT TL spine reformats were reviewed to determine identification of TL spine fracture in each report. Fracture type and location were documented. Of the 896 patients, 66 (7.4%) had fractures of the TL spine identified on either CT CAP or CT TL spine. Of these 66 patients, 40 (60.6%) had fractures identified on both CT CAP and CT TL spine and 24 (36.4%) had fractures identified on CT TL spine images alone. Fourteen patients required treatment with surgery or bracing, 4 (28.6%) of which had fractures identified on reformatted TL spine imaging only. In conclusion, a significant number of fractures are detected on TL spine reformats that are not identified on CT CAP alone, altering patient management in a few cases and suggesting that dedicated TL spine reformats should be a standard part of the work-up of blunt trauma patients.

Thrombosis of posterior condylar vein with extension to internal jugular vein; a rare radiological finding in traumatic brain injury.

Dear Editor, The posterior condylar canal is located posterior to the occipital condyle and transmits the posterior condylar vein, one of the largest emissary veins in the retromastoid region.[1,6] This vein usually origins from superior bulb of the internal jugular vein or less frequently from the medial side of the distal portion of the sigmoid sinus and connect to the suboccipital venous plexus.[5,9] We report a patient with occipital bone fracture coursing through the posterior condylar canal causing thrombosis of posterior condylar vein with extension to internal jugular vein. To the best of our knowledge, thrombosis of posterior condylar vein with subsequent extension to major venous sinuses due to trauma has not been reported yet. A 50-year-old patient was brought to the emergency department following a fall from 15 steps. Initial head computed tomography (CT) scan demonstrated bilateral inferior frontal hemorrhagic contusions, traumatic subarachnoid hemorrhage in bilateral frontal and right temporal lobe, and linear occipital bone fracture extending to the posterior condylar vein on the right side. There was no extension of fracture line to the major dural venous sinuses. Subsequent CT venography (CTV) demonstrated thrombosis of right posterior condylar vein with extension to upper aspect of right internal jugular vein causing nonocclusive thrombosis [Figure 1]. Given the presence of hemorrhagic brain contusions and nonocclusive nature of thrombosis in the internal jugular vein, patient was not considered an appropriate candidate for anticoagulation and was managed conservatively. Follow-up CTV in 48 h demonstrated stable thrombosis with no extension. Figure 1 Axial CT scan demonstrates linear occipital bone fracture with extension to the right posterior condylar canal (a white arrow). Axial and sagittal oblique CT Venogram (b and c) demonstrate right condylar vein thrombosis (white arrow) with extension to ... Emissary veins connect the extracranial venous system with the intracranial venous sinuses. Although they are usually small in healthy people, they may enlarge in patients with increased intracranial pressure, in patients with high-flow vascular malformations or severe hypoplasia/aplasia or obstruction of the jugular veins. They may also serve as a conduit for retrograde spread of infection or tumors. Familiarity with major posterior fossa emissary veins is important to avoid misdiagnosis as abnormal findings and also to prevent surgical complications, which can result in intracranial hemorrhage, air embolism, and fatal increases in intracranial pressure.[7] The role of traumatic close head injuries as an important etiology of cerebral venous sinus thrombosis has been demonstrated in multiple studies.[2] Extension of skull fractures to venous sinuses had been reported in 10.4% and 13% of patients in two recent large studies.[3,8] Delgado Almandoz et al. demonstrated traumatic dural sinus thrombosis in 40.7% of patients with blunt head trauma with skull fractures extending to dural venous sinuses or jugular bulb, and more than half of those were occlusive.[3] In a more recent study, Rivkin et al. found thrombosis of at least one venous sinus or jugular bulb in 34.9% of patients (20.6% nonocclusive, 14.3% occlusive).[8] Fujii et al. also evaluated 97 patients with skull fractures crossing venous sinuses and found 22.4% of them to have thrombosis.[4] The indication for performing CTV in all of these studies was extension of skull fracture line to the major dural sinuses including superior sagittal sinus, transverse sinus, sigmoid sinus, or jugular bulb, and, to the best of our knowledge, traumatic thrombosis of posterior condylar vein with subsequent extension to major venous sinuses has not been reported yet. Development of venous sinus thrombosis in the setting of blunt trauma can result in poor clinical outcome resulting from multiple neurological complications including increased intracranial pressure, hemorrhagic venous infarctions, and increase in seizure frequency, with mortality rates as high as 50% for occlusive venous thrombosis.[3,4,8] Treatment of dural venous sinus thrombosis in the setting of trauma might be very challenging and only a small minority of patients with occlusive venous sinus thrombosis has been reported in prior studies.[3] In conclusion, in the setting of blunt head trauma, extension of the fracture lines to the posterior condylar canal can cause condylar vein thrombosis with secondary extension to major dural venous sinuses. Increase in awareness of this anatomical structure and routine CTV when there is extension of skull fracture line to the major dural sinuses is important for appropriate diagnosis.

ACR Appropriateness Criteria Blunt Chest Trauma

Imaging is paramount in the setting of blunt trauma and is now the standard of care at any trauma center. Although anteroposterior radiography has inherent limitations, the ability to acquire a radiograph in the trauma bay with little interruption in clinical survey, monitoring, and treatment, as well as radiography's accepted role in screening for traumatic aortic injury, supports the routine use of chest radiography. Chest CT or CT angiography is the gold-standard routine imaging modality for detecting thoracic injuries caused by blunt trauma. There is disagreement on whether routine chest CT is necessary in all patients with histories of blunt trauma. Ultimately, the frequency and timing of CT chest imaging should be site specific and should depend on the local resources of the trauma center as well as patient status. Ultrasound may be beneficial in the detection of pneumothorax, hemothorax, and pericardial hemorrhage; transesophageal echocardiography is a first-line imaging tool in the setting of suspected cardiac injury. In the blunt trauma setting, MRI and nuclear medicine likely play no role in the acute setting, although these modalities may be helpful as problem-solving tools after initial assessment. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Cocaine-Induced Cervical Emphysema and Pneumomediastinum

Cervical emphysema and pneumomediastinum are rare con- ditions, especially outside the setting of blunt trauma. Here we describe a case of a 31-year-old male with a history of cocaine use presenting with cough, odynophagia, neck pain, and neck swelling after forcefully blowing his nose to relieve cocaine-associated congestion and obstruc- tion. Physical exam demonstrates crepitus along the neck and clavicu- lar regions. Imaging shows cervical emphysema, pneumomediastinum, and a nasopharyngeal fistula. We discuss presentation, causes, diagno- sis, and management of cervical emphysema and pneumomediastinum.

Short answer question case series: abdominal swelling, bruising and pain after fall

A 53-year-old male with a history of coronary artery disease presents to the emergency department (ED) with abdominal pain and bruising after a fall onto his abdomen 2 h ago....

Unusual case of pancreatic ascites and pancreatic pleural effusion following endoscopic retrograde cholangiopancreatography

Introduction: Pancreatic fistula is the most common complication of pancreatic injury in the setting of blunt trauma and chronic alcoholic pancreatitis. Internal pancreatic fistulas (IPF) are most commonly cause by disruption of the pancreatic duct due to pancreatitis, and leakage from a pancreatic pseudocyst. We present a case of post­ endoscopic retrograde cholangiopancreatography (ERCP) pancreatic leak complicated by pancreatic pleural effusions and pancreatic ascites. Case Report: An 18­year­old Hispanic female was admitted with persistent right upper quadrant and epigastric pain, abdominal distention, constipation, leukocytosis and elevated pancreatic enzymes, with history of recent laporoscopic cholecystectomy due to cholelithiasis three months ago. She was diagnosed with choledocholithiasis, underwent successful ERCP, and was discharged home. After 24 hours of discharge, she developed symptoms of systemic inflammatory response syndrome and constipation. Computed tomography (CT) scan of abdomen and paracentesis revealed left sided ascites and plural effusion with high amylase content and no infection. She was diagnosed as suffering from pancreatic ascites and pancreatic pleural effusion following endoscopic retrograde cholangiopancreatography, secondary to internal pancreatic fistula. She received octreotide and a conservative approach to her condition, and had a good response to therapy. Conclusion: In our patient diagnosis was made by finding elevated amylase and protein content in the ascitic and pleural fluids plus CT scan revealed effusion and ascites and managed conservatively. The use of octreotide in such cases is established, and has been successful in our experience.

Traumatic brachiocephalic artery pseudoaneurysm following penetrating injury on the contralateral side

Introduction: Trauma to the brachiocephalic artery is uncommon, but is associated with significant morbidity and mortality. The development of pseudoaneurysm following both penetrating and blunt trauma have been well documented, mostly in the setting of blunt trauma. Case Report: A highly unusual case of a patient who developed a pseudoaneurysm of the brachiocephalic artery on the side contralateral to the side of the original penetrating injury has been reported. Conclusion: Pseudoaneurysm of the brachiocephalic artery following penetrating neck injury in the contralateral side is exceeding rare. It may remain symptomatic and present long after the initial injury. Clinician must have a high index of suspicion for such potentially serious injury.

Isolated Submandibular Gland Injury in the Setting of Blunt Trauma

Isolated Submandibular Gland Injury in the Setting of Blunt Trauma

Conservative management of esophageal perforation after a fall

INTRODUCTIONEsophageal perforation in the setting of blunt trauma is rare, and diagnosis can be difficult due to atypical signs and symptoms accompanied by distracting injury. PRESENTATION OF CASEWe present a case of esophageal perforation resulting from a fall from height. Unexplained air in the soft tissues planes posterior to the esophagus as well as subcutaneous emphysema in the absence of a pneumothorax on CT aroused clinical suspicions of an injury to the aerodigestive tract. The patient suffered multiple injuries including bilateral first rib fractures, C6 lamina fractures, C4–C6 spinous process fractures, a C7 right transverse process fracture with associated ligamentous injury and cord contusion, multiple comminuted nasal bone fractures, and a right verterbral artery dissection. Esophageal injury was localized using a gastrograffin esophagram to the cervical esophagus and was most likely secondary to cervical spine fractures. Because there were no clinical signs of sepsis and the esophagram demonstrated a contained rupture, the patient was thought to be a good candidate for a trial of conservative management consisting of broad spectrum intravenous antibiotics, oral care with chlorhexadine gluconate, NPO, and total parenteral nutrition. No cervical spine fixation or procedure was performed during this trial of conservative management. The patient was received another gastrograffin esophagram on hospital day 14 and demonstrated no evidence of contrast extravasation. DISCUSSIONEarly diagnosis and control of the infectious source are the cornerstones to successful management of esophageal perforation from all etiologies. Traditionally, esophageal perforation relied on a high index of clinical suspicion for early diagnosis, but the use of CT scan for has proved to be highly effective in diagnosing esophageal perforation especially in patients with atypical presentations. While aggressive surgical infection control is paramount in the majority of esophageal perforations, a select subset of patients can be successfully managed non-operatively. CONCLUSIONIn the setting of blunt trauma, esophageal perforation is rare and is associated with a high morbidity. In select patients who do not show any clinical signs of sepsis, contained perforations can heal with non-operative management consisting of broad spectrum antibiotics, strict oral hygiene, NPO, and total parenteral nutrition.

Screening Cervical Spine CT in the Emergency Department, Phase 2: A Prospective Assessment of Use

The National Emergency X-Radiography Utilization Study Low-Risk Criteria were established to identify patients with a low probability of cervical spine injury in whom imaging of the cervical spine was unnecessary. The purpose of this study was to ascertain the number of unnecessary cervical spine CT studies on the basis of proper application of established clinical guidelines and, secondarily, to determine indications for ordering studies in the absence of guideline criteria. All patients presenting to a level I trauma center for whom a screening cervical spine CT was ordered in the setting of blunt trauma were eligible for enrollment. For each study, the requesting clinician completed a survey regarding study indications. CT examinations were evaluated by a board-certified radiologist blinded to survey data to determine the presence or absence of cervical spine injury. Of 507 CT examinations, 5 (1%) were positive and 497 (98.0%) were negative for acute cervical spine injury. Five studies (1%) were indeterminate for acute injury but demonstrated no abnormality on subsequent imaging and clinical follow-up. Of the 502 studies without cervical spine injury, 81 (16.1%) were imaged despite meeting all 5 NEXUS criteria for nonimaging. Of these, the most common study indication was dangerous mechanism of injury (48.1%) followed by subjective neck pain (40.7%). Strict application of NEXUS criteria could potentially reduce the number of screening cervical spine CT scans in the setting of blunt trauma; this change would avoid a considerable amount of unnecessary radiation and cost.

Seat-belt induced bladder rupture in a car accident: A case report

Injury to the lower urinary tract is relatively uncommon in the setting of blunt trauma. Identification of serious intra-abdominal injury is often challenging. Bladder injuries occur most often from external force and are often associated with pelvic fractures. Typically, these patients have a history of pelvic trauma, which is fairly straightforward for motor vehicle accidents, deceleration injuries, or assaults to the lower abdomen. Here, we describe a case of bladder rupture not associated with pelvic fracture in a 58-year-old man. The “seat-belt sign” and gross hematuria were present. Emergency surgery was performed with excellent results and he was discharged in stable condition.

FAST as a predictor of clinical outcome in blunt abdominal trauma

Background. Peer-reviewed literature demonstrates increasing support for the use of focused abdominal sonography in trauma (FAST) in the setting of blunt trauma, one study demonstrating the sensitivity and specificity of FAST for the detection of free fluid to be 0.64 - 0.98 and 0.86 - 1.00, respectively, compared with abdominal CT. Utilising ultrasound in trauma triage increases efficiency and cost-effectiveness and reduces reliance on CT, compared with using CT alone. There is little evidence to support relying solely on a negative FAST and physical examination for patient management.&#x0D; Method. A retrospective descriptive study of 172 adult patients who received FAST for the evaluation of blunt abdominal trauma between 22 July 2007 and 21 January 2008 at Tygerberg Hospital was performed. Ultrasound findings were correlated with CT scan findings, operative findings if managed surgically, clinical outcomes whether managed surgically or conservatively, as well as postmortem findings in deceased patients.&#x0D; Results. FAST was negative in 147 (85.5%) patients. Twenty-four (16.3%) of these patients died from all-cause mortality, none of which was due to intra-abdominal injury. &#x0D; Seven patients with negative FAST underwent CT scan owing to change in clinical course, and 3 patients with negative FAST underwent laparotomy owing to change in clinical course, with positive findings in 2 patients – a bowel injury requiring resection (not seen on CT) and a diaphragmatic rupture seen on CXR. A negative FAST was shown to be an excellent predictor for the absence of significant intra-abdominal trauma.&#x0D; The mortality rate among 25 FAST positive patients was 24% (N=6). Only one of these patients (with a splenic rupture) was suspected to have died from abdominal pathology.

Range of elbow movement as a predictor of bony injury in children

BackgroundThe aim of this study was to determine whether a normal range of elbow movement can be used as a rule out tool for significant injury after blunt trauma in...

Recognition and Management of the Spectrum of Acute Laryngeal Trauma

BackgroundBlunt laryngeal trauma frequently takes place in the setting of more significant injuries. In the setting of multiple injuries or, more importantly, as an isolated event, missed injuries to the laryngotracheal complex can have devastating results. More importantly, underestimation of the severity of injury can result in an airway that becomes quite difficult to manage. However, early recognition and management of laryngotracheal injuries can result in minimal morbidity and the need for minimal long-term intervention. ObjectivesOur goal is to heighten awareness of the severity of blunt laryngotracheal trauma and reduce both acute and long-term sequelae. Case ReportWe present a series of cases representing a spectrum of seemingly benign neck injuries requiring a diversity of interventions. The cases represent worsening gradations of laryngeal trauma, and the differing presentation, work-up, and management scenarios are discussed. ConclusionsExpedient evaluation, treatment, and management of blunt laryngeal trauma results in favorable outcomes. Awareness of the potential for significant injury in the presence of benign examination based on the history of injury and confirmed by radiographic or endoscopic evaluation is paramount. Although minimal findings on examination and stable patients in the setting of blunt trauma to the neck may be as innocuous as it seems, the severity of injury may “lie beneath.”

Reply: Severe preprocurement blunt trauma to the liver-Is there a need for back-table cutdown?

We read with interest the letter by Oniscu et al. in response to our article published in the March issue of Liver Transplantation. In response to the question of whether there is a need for back-table cutdown, we can respond that at times the answer is yes. The strategy that we feel needs to be in place whenever there is known or occult damage, particularly to the right lobe of a donor liver, involves first ensuring that abdominal multiorgan procurement can be achieved even in the setting of ongoing hemorrhage from the right lobe of the liver or other solid organs. This may require packing of solid organs, including the right lobe of the liver; this was required on 3 occasions in our experience. On one occasion, packing of the right lobe of the liver facilitated in situ splitting to obtain a lateral segment graft for subsequent implantation into a pediatric recipient. Second, an assessment needs to be made, partly on the basis of the hemodynamic stability of the donor, concerning what may be possible in the setting of visible trauma to the liver. In the 2 cases in our report, in which back-table cutdown was ultimately required of the donor liver, it was decided to expedite multiorgan procurement and deal with the trauma to the liver on the back-table. It is of note that in both of these cases there was capsular damage (significant tears) as well as significant parenchymal trauma to the right lobe, in contrast to the case cited by Oniscu et al. However, we agree with Oniscu et al. that the meticulous back-table inspection of deceased donor liver allografts in the setting of blunt trauma is important and should include an examination of the vasculature, in which there may be occult injury as well.